Urological morbidity following pelvic surgeries

1. PROF S.SUBBIAH et al.
UROLOGICAL MORBIDITY
FOLLOWING PELVIC SURGERIES
DEPARTMENT OF SURGICAL ONCOLOGY
CENTRE FOR ONCOLOGY
GOVT ROYAPETTAH HOSPITAL

2. PROF S.SUBBIAH et al.
RETROPERITONEAL SPACES
• Virtual- not naturally present but are created by dissection to access vital
structures underneath or to separate or retract the organs during dissection
• Bilateral:
a. Pararectal space
b. Paravesical space
• Unilateral/midline:
a. Prevesical space
b. Rectovaginal space
c. Retrorectal or presacral space
• ROOF- peritoneal lining
• FLOOR- levator ani muscle

3. PROF S.SUBBIAH et al.
PARARECTAL SPACE
• Ureter divides it into
• Medial – Okabayashi space
• Lateral – Latzko space
• Japanese surgeon- Hidekazu Okabayashi who demonstrated the first nerve-sparing
radical hysterectomy in Kyoto Imperial Hospital in 1921
• Okabayashi space contains nerve fibers of the superior hypogastric plexus that traverse
from the rectosigmoid junction and combine to form the hypogastric nerve, and then
further at the level of the uterovesical junction form a plexus finally innervating the
bladder

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5. PROF S.SUBBIAH et al.
APPROACH TO PARARECTAL SPACE
• In respect to infundibulopelvic ligament
• Endometriotic approach (medial approach)
• Oncological approach (lateral approach )

6. PROF S.SUBBIAH et al.
• not lined by peritoneal epithelial lining
• midline small retroperitoneal space confined within the anterior surface of uterus and
the ureter inserting into the bladder
• lined by the cervico vesical fascia and contains parasympathetic nerves innervating
the bladder
• Careful dissection at this space helps in nerve-sparing radical hysterectomy.
Yabuki space

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INNERVATION OF BLADDER

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PHYSIOLOGY OF MUSCULATURE OF
BLADDER

11. PROF S.SUBBIAH et al.
AUTONOMOUS BLADDER
• Complete denervation of the parasympathetic plexus
• Automatic rhythmic contraction will develop ( tone and capacity)
• Early in newborn , weeks to months in adults
• Sensations preserved – due to stretch – peritoneal wall

12. PROF S.SUBBIAH et al.
• Three possibilities:
• part of innervation interrupted- return to normal within few days
• Fibres are damaged but not cut- longer period of disability
• weeks to months for recovery
• Complete denervation- prolonged disability
sluggish and sensationless bladder
patient may adopt to control over urethral sensation

13. PROF S.SUBBIAH et al.
INJURY TO AUTONOMIC NERVES
• Damage to the sacral splanchnic nerves may lead to detrusor denervation and decreased
sensitivity of the bladder – associated symptoms are difficulty in bladder emptying,
overflow incontinence and loss of sensation to fullness of the bladder.
• Posterior tilting of the bladder, which may occur after an APE, may also cause difficulty in
bladder emptying.
• This may be further marked in patients who have undergone a hysterectomy.
• Loss of sympathetic innervation, which may be the result of damage to the hypogastric
nerves, may result in urgency and stress incontinence
• Urinary tract infection may develop secondary to overflow incontinence

14. PROF S.SUBBIAH et al.
• Hypogastric nerve can be sacrificed during surgery in the uterosacral ligament
and rectovaginal ligament
• The pelvic sphlachnic nerve can be traumatized during surgery in the deep
uterine vein in the cardinal ligament
• The bladder branch of the pelvic nerves is usually affected during surgery in the
vaginal blood vessels of the paracolpium.
• In the cardinal ligament division of the deep uterine vein reveals the pelvic
sphlachnic nerve, while division of the posterior leaf of the vesicouterine
ligament reveals the bladder branch `
PLACES AT RISK IN RADICAL HYSTRECTOMY

15. PROF S.SUBBIAH et al.
• Involuntary contractions of the bladder, which may cause overactive
bladder incontinence
• On urodynamics, detrusor overactivity with involuntary rises in
bladder pressure can be seen—usually associated with leakage
• Outlet abnormalities resulting in a failure to store usually include a
decrease in outlet resistance
• Stress urinary incontinence
FAILURE TO STORE

16. PROF S.SUBBIAH et al.
• Anticholinergic medications- decrease the pressures within the
bladder during storage as well as marginally increase bladder volumes
• Refractory to anticholinergic medications
• maximizing the doses
• Neuromodulation
• enterocystoplasty (bladder augmentation with bowel)
FAILURE TO STORE:TREATMENT

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• Inadequate bladder contractions for emptying.
• bladder with insufficient contractile force to adequately empty the
bladder
• On urodynamic assessment - low pressure, weak, intermittent
contractions of the detrusor muscle with incomplete bladder
emptying
FAILURE TO EMPTY

18. PROF S.SUBBIAH et al.
• encouraged to perform clean intermittent catheterization(CIC)
• CIC is performed with 12 to 14 French low friction catheter every 4 to
6 hours.
• If the patient remains unable to void, they are evaluated using
pressure-flow urodynamic studies at approximately 2 to 3 months
postoperatively.
FAILURE TO EMPTY:TREATMENT

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• CIC protocol can be adjusted based on the storage pressures and
bladder capacity at the time of urodynamic evaluation.
• It may take up to 6 months for bladder function to return.

20. PROF S.SUBBIAH et al.
ROLE OF PREOPERATIVE URODYNAMIC
STUDY
• Lin et al – reported 83% patients with carcinoma cervix had abnormal
urodynamic study before radical hysterectomy
• Chen et al – reported that abnormal detrusor instability in women
with preoperative carcinoma cervix than patients with CIN III

21. PROF S.SUBBIAH et al.
POSTOPERATIVE URODYNAMIC STUDY
• Generally acute voiding symptoms disappears after 6-12 months of
hysterectomy
• Improvement of clinical symptoms alone – unreliable indicator of
improvement in bladder function
• May be due to compensatory mechanisms
• Substitute sensation ,abdominal straining ,voiding technique

22. PROF S.SUBBIAH et al.
• Only symptom that showed improvement over time is sensation
• No significant change in the urodynamic study ( complete
denervation)
• Post surgery – 2 weeks and after 6 months

23. PROF S.SUBBIAH et al.
Minimizing morbidity
• NERVE SPARING HYSTERECTOMY
• Radicality closely related to morbidity
• Low volume disease – type II hysterectomy –preserve voiding
function
• ZULLO ET AL – extent of vaginal resection propotional to bladder
morbidity

24. PROF S.SUBBIAH et al.
NERVE SPARING HYSTERECTOMY
• Meticulously divide the posterior leaf of the vesico-uterine ligament
• Separation of the inferior vesical vein in the posterior leaf of the
vesicouterine ligament, the bladder branch from the inferior
hypogastric plexus can be identified and preserved
• Uterine branch has to be divided

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OKABAYASHI VS NERVE SPARING

27. PROF S.SUBBIAH et al.
RECTAL SURGERIES
• Key zones at risk of pelvic nerve injury during rectal surgery:
• Ligation of the inferior mesenteric artery
• Posterior rectal dissection ( SACRAL PROMONTARY)
• Lateral rectal dissection
• Anterior rectal dissection

28. PROF S.SUBBIAH et al.
STEPS TO PREVENT INJURY
• Ligation of the IMA should be performed 1.5–2 cm from its aortic origin to
avoid damage to SHP fibres lying in front of the aorta
• Avoid mass clamping of the IMA which may increase damage to the left
trunk of the SHP due to its closer proximity compared with the right trunk
of SHP located in the aortocaval plane
• Preserve Gerota’s fascia during mobilisation of the ureter and gonadal
vessels as these contain SHP fibres
• At the level of the sacral promontory, the transition from mesosigmoid to
mesorectum is an area where damage is possible to the presacral plexus
and hypogastric nerves.

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• To avoid the wrong plane of dissection, it is important to dissect
only immediately posterior to the superior rectal artery and to
remain within the plane anterior to the parietal presacral fascia.
• It has been suggested that this should be approximately 2 cm
anterior to the promontory

31. PROF S.SUBBIAH et al.
Nerve-sparing radical retropubic
prostatectomy
• The apical approach to the NVB (the ‘Walsh technique’)
• nerves dissection is initiated at the apical level with primary isolation of the
urethra
• The lateral approach to the NVB (The Ruckle and Zincke technique)
• neurovascular bundles are primarily dissected off the lateral prostate and only
subsequently is the urethra transected

32. PROF S.SUBBIAH et al.
• Walsh recommends to proceed to secondary excision of the NVBs
(which should always be spared in the first instance) in the presence
of one of the following intraoperative findings:
• 1. induration in the lateral pelvic fascia
• 2. adherence of the NVB to the prostate while it is being released
• 3. inadequate tissue covering the posterolateral surface of the
prostate once the prostate has being removed

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INTROPERATIVE NERVE MONITORING

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TAKE HOME POINTS
• Bladder morbidity –part and parcel of radical pelvic surgeries
• THOROUGH ANATOMICAL KNOWLEDGE
• NERVE PRESEVING TECHNIQUES
• EARLY RECOGNITION AND MANAGEMENT